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CARDIAC DISEASE AND
PRE-PARTICIPATION SCREENING IN BOXING
Daniel Azimzadeh
MBChB, School of Medicine, University of Liverpool1
Introduction
Sudden cardiac death (SCD) in athletes is usually unexpected in fit and
asymptomatic individuals. Hypertrophic Cardiomyopathy (HCM) is the
most common aetiology in under 35’s, with a wide range of other causes.
The incidence of SCD ranges from 1:28,000 - 300,000 in studies from
Italy, America and Canada. Identifying those at risk and removing them
from sport participation can avoid potential fatalities; consequently,
optimal screening, striking a balance between cost and effectiveness is
essential. Pre-participation screening (PPS) guidelines markedly vary
around the world. In Italy PPS is mandatory for all athletes in all sports,
but this is not the case around the rest of Europe. First team elite
footballers (soccer) in Europe are mandated by UEFA to have PPS.
Athletes with documented cardiac disease may also be at risk of SCD
and there are European guidelines for further investigation and eligibility
to continue sports participation.
Boxing poses a high cardiac demand with boxers’ VO2max (maximum
level of oxygen utilised during exercise) ranging from 55.8 to
63.8ml/kg/min. In addition, lactate levels are elevated, indicating the
highly anaerobic nature of the sport, ultimately placing a greater
requirement for cardiac output. Lactate levels have been demonstrated to
rise up to 13.6±3.2mmol/l with just four 2-minute rounds, with a 1minute break in between each round. This is up to twice that of
footballers at 8.4mmol/l.
Aims:
In light of the potential for SCD and the cardiac demand for boxing in
comparison to football, we propose the following objectives:
1. The cardiac conditions which constitute ineligibility of participation in
boxing, and how it differs from football.
2. Current worldwide cardiac screening in boxing
3. A review of literature available with regards to SCD and cardiac
disease in boxing.
Methodology
A list of boxing regulatory bodies was established with published medical
eligibility guidelines obtained. US State Athletic Commissions’ guidelines
were compared with US National Athletic PPS guidelines and European
consensus documents. PPS and eligibility to compete with specific
cardiac diseases was tabulated for for comparison.
A literature search was carried out using Medline and Ovid for any
previous studies or case reports on SCD in boxing or cardiac disease as
a consequential injury.
Results
(36th
The comprehensive US overview
Bethesda Conference 2005) of
eligibility for athletes to compete and management plans was compared
with the European Society of Cardiology’s (ESC) consensus document
(EHJ 2005). Additional guidelines from 8 boxing regulatory bodies were
located (n=2 amateur & n=6 professional). The marked variation in opinion
and eligibility criteria amongst various organisations and authors was
documented.
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Eligibility to compete with known Cardiac Disease - Boxing:
Arrhythmias: Asymptomatic bradycardia, increasing on exertion, is
deemed acceptable by Bethesda and ESC, but tachycardia requires
treatment prior to participation. In addition, there is an absolute
contraindication of pacemaker insertion due to risk of collision. There are
discrepancies between ESC and Bethesda regarding atrial flutter or
fibrillation, supraventricular & ventricular tachycardias, ventricular
flutter or fibrillation and congenital third degree heart block in
investigation, treatment and eligibility for sport participation.
Congenital Cardiac Disease: Overall, Bethesda, ESC, ABAE, Canadian
Professional Boxing Federation (CPBF) and World Series of Boxing
(WSB) conditionally allow certain defects. However, EBA and World
Boxing Council (WBC) regard any congenital cardiac defect as an
absolute contraindication. The main inconsistencies between Bethesda
and ESC comprise conditional approval of aortic coarctation and
tetralogy repair. All sources agree that symptomatic atrial and
ventricular septal defects, patent ductus arteriosus and untreated
cyanotic heart disease are contraindications.
Valvular Heart Disease: ESC and Bethesda disagree regarding
participation in boxers with, mitral & aortic stenosis or regurgitation and
tricuspid regurgitation, but both deem mild mitral regurgitation as
acceptable. AIBA, WBC and EBA however do not accept any history of
valvular heart disease or repair.
Myocardial & Pericardial Disease: There is an unquestionable
contraindication for any cardiomyopathy amongst ESC, Bethesda, AIBA,
EBA, ABAE, WBC, WSB and Oriental & Pacific Boxing Federation .
Furthermore, connective tissue diseases (Marfan and Ehlers-Danlos
syndrome) and infiltrative diseases are also contraindicated by
Bethesda. Finally, infective cardiac wall conditions (pericarditis and
myocarditis) are only permissible after confirmed treatment.
Coronary Artery Disease (CAD), and Hypertension: CAD universally
debars boxers from participation with similar opinions on those who show
cardiac risk factors with no actual disease. Furthermore, many
organisations show a cautious approach to stage 1 hypertension
(140/90mmHg), ranging from an absolute contraindication to referral for
further investigation; ESC, AIBA, WSB and EBA allow participation
providing medication control. Stage 2 hypertension (>160/100mmHg)
and malignant hypertension is a concurrent contraindication.
Eligibility to compete with known Cardiac Disease - Football:
Bethesda and ESC recommendations for participation in football show few
key differences. Firstly, in Bethesda (but not ESC) the presence of a
pacemaker may be acceptable with the use of protected padding.
Furthermore, Bethesda states post-surgical great artery transposition
repair is acceptable but remains disallowed in ESC. Bethesda permits
boxers and footballers to compete with mild mitral stenosis, whereas
ESC only permits footballers. Finally, both Bethesda and ESC conditionally
allow stage 2 hypertension in footballers, unlike in boxers.
Boxing Pre-participation Screening for Cardiac Disease:
World Amateur and Professional organisations: PPS in ABAE, AIBA
and United States Amateur Boxing (USAB) require questionnaire and
cardiac examination only. In contrast, WBC, USAB and AIBA require an
additional ECG with discovered abnormalities or in older boxers. There
are, however, no specified screening requirements for WBO and WBA.
European Society of Cardiology (ESC): It is recommended that all
athletes under 35 undergo PPS questionnaire, examination and ECG. If
any abnormalities then echocardiogram is performed. This is adopted in
Italy for all sports and by major sporting organisations in rest of Europe.
US State Athletic Commissions (SAC): PPS in boxers is highly varied
amongst US SAC (see figure below). Alarmingly, Michigan state requires
no cardiac screening for competition and only four states offer a baseline
physical examination & ECG and screening for older athletes. 70% of
SAC request a baseline examination, although 23% require this only
prior to a fight. In addition, only 17% SAC routinely require a baseline
ECG. Only 47% specify routine baseline requirements for older boxers:
(physical: 11%; ECG: 23%; advanced tests: 23%). Also, only 17% of SAC
require PPS physical and ECG.
Proportion of State Athletic Commissions (SAC) requiring
certain cardiac assessments (%) vs. ESC Recommondations
Discussion
Eligibility to compete with known Cardiac Disease – Boxing
Consensus guidelines for all sports have been published in USA (Bethesda
36th) and Europe (ESC). There are further guidelines from Boxing
Organisations and Commissions around the world and even within specific
US States. There is variation between these guidelines, but some are
unanimous (HCM, some arrhythmias, congenital defects & valve disease).
USA (Bethesda 36th) vs. European (ESC) Consensus Guidelines:
There are many similarities with variation attributed to ‘cultural, social, and
legal backgrounds’. It is recommended that a unified document should be
published to alleviate confusion. Furthermore, differences between
participation in boxing compared to football are limited; there are certain
increased leniencies amongst the consensus documents to reflect the
increased cardiac demand of boxing.
Boxing Pre-participation Screening for Cardiac Disease:
There are marked differences in PPS between World Amateur and
Professional Organisations, ESC and US State Athletic Commissions. The
ESC involves questionnaire, examination and ECG in all. Whilst most other
organisations offer at least an examination, a boxer can compete in
Michigan State without even this. Many states do not offer a baseline ECG
or any additional screening for older boxers.
100%
90%
80%
70%
60%
None
50%
Case-by-case basis
40%
Pre-fight
30%
Pre-training
20%
10%
0%
Physical
Examination
ECG
Older Boxer:
extra screening
SAC: Physical
and ECG
ESC: Physical
and ECG
The debate of whether a routine ECG is necessary for athlete screening is
relevant. In Italy, a 26-year study demonstrated the inclusion of ECG led to
an 89% reduction in SCD in athletes. This is contrary to the American
Heart Association screening, based on questionnaire and examination
alone. In boxing, there has been a call to introduce a routine ECG although
the British Board of Boxing Control has no formal screening protocol. To
contrast, the Football Association of England offers an ECG on all young
participants, in spite of its lower cardiac exertion profile as a sport.
Literature review: Cardiac-related issues in Boxing
Literature review: Cardiac-related issues in Boxing
There is limited data with few observational studies and case reports.
There is a low prevalence of SCD within boxing, although data is limited
and therefore this conclusion cannot be confidently drawn. This may be
due to the rarity of such events and its overshadowing neuropsychiatric
and craniofacial issues, which is beyond the scope of this report.
Of 15 boxers with ECGs recorded before and immediately after a bout, 3
boxers showed significant ventricular repolarisation abnormalities likely
due to boxing related sympathetic over-activity.
There are two case reports: a 32-year-old professional boxer with
Myocardial Contusion (MC), and a 65-year-old retired boxer with
pericardial constriction, chylous ascites and chylothorax. The risk of
such events are a rarity due to glove padding.
SCD in athletes (including boxers) from a French and American sample
showed that HCM was the cause in 30% and 50% of the individuals
respectively, but the proportion of boxers is unspecified. Similar French
data compiled over 19 years, showed 1 boxer died from arrhythmogenic
right ventricular cardiomyopathy during exercise. Finally, a 6-year
German epidemiological data analysis showed a 59 year-old-boxer with
SCD of unknown aetiology.
Conclusion
Boxers with certain cardiac conditions may be permitted or banned from
participation, purely based on the region or organisation delivering the
assessment; this variation also exists for PPS. Consequently, global criteria
should be devised. Furthermore, there is a strong argument for the
inclusion of a baseline ECG screening for all competitive boxers. A pilot
study comprising a large sample of professional boxers undertaking ECG
screening in addition to routine history and examination at baseline is
recommended.
Acknowledgements
Prof. John Somauroo, Sports Cardiologist, Countess of Chester NHS Trust
Dr. Nigel Jones, Dr to British Boxing Board of Control and Liverpool FC